Healthcare Provider Details

I. General information

NPI: 1639933286
Provider Name (Legal Business Name): RENEW AESTHETICS AND REGENERATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 112TH ST E STE 300
PUYALLUP WA
98373-4315
US

IV. Provider business mailing address

16616 139TH AVE E
PUYALLUP WA
98374-8830
US

V. Phone/Fax

Practice location:
  • Phone: 253-651-9263
  • Fax:
Mailing address:
  • Phone: 619-669-8847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL LORAH
Title or Position: CHIEF EXECUTIVE OFFICER, CLINIC OWN
Credential:
Phone: 619-669-8847